Magazine article Drug Topics

When Pharmacists Have the Final Say on Drug Orders

Magazine article Drug Topics

When Pharmacists Have the Final Say on Drug Orders

Article excerpt

Veto power over inappropriate drug orders is a dream for many hospital pharmacists. At the University of Wisconsin Hospital and Clinics, it is reality.

"Between 96% and 97% of our scripts are written by trainees and fellows," explained Lee Vermeulen, director of Wisconsin's Center for Drug Policy. "We wanted clinical pharmacists to have authority over their prescribing because pharmacists generally know more about drugs. House staff just are not qualified to make the decision on high-risk medications. We're helping our attending physicians solve a problem."

Attending physicians agree. The hospital's pharmacy and therapeutics committee has voted to expand what began as a trial program in the trauma unit in the mid1990s to the entire hospital.

Pharmacist oversight of all antiinfective orders should begin this summer. Other product categories will be added later, Vermeulen said.

"It's not uncommon for pharmacists to review scripts written by residents," said Carla Frye, scientific affairs associate at ASt-. But it is less common to give pharmacists veto power over drug orders-even orders from physicians in training. The key is that this is not a blind change to a physician order," said Frye. "It is a carefully thought-out system that has been approved by the P&T committee."

It is also a system that is evolving. The program began in 1996, when pharmacists started checking trauma center orders for albumen, sedatives, anti-infectives, potassium chloride, and other specific product categories. The current pharmacist review will eventually be replaced by an automated review as part of a planned computerized physician order entry (CPOE) system.

If a physician orders vancomycin without serum creatinine levels, for example, CPOE will reject the order the same way a pharmacist rejects it under the current manual review system. "We're building those decision trees right now," Vermeulen said. "CPOE will make the same kinds of guideline decisions that pharmacists make today, but faster."

CPOE review will also ease the load on the facility's 90-some clinical pharmacists who are overseeing orders for 450 beds and 90 specialty clinics. There are about 1,200 faculty physicians on staff.

Formulary and practice guidelines are key to pharmacist review of drug orders. If the order meets guidelines, Vermeulen said, it is filled. If it violates guidelines, a pharmacist stops the order and contacts the house staff who wrote it.

That's when the negotiations begin. The physician either agrees that the order is inappropriate and changes it, or explains why the guidelines do not fit the specific case.

"Everyone is aware that guidelines don't fit every occurrence and every patient," Vermeulen said. …

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